Clarithromycin attenuates mastectomy-induced acute inflammatory response

Evidence-Based Medicine: Systemic Perioperative Antibiotic Prophylaxis for Prevention of Surgical-Site Infections in Plastic and Reconstructive Surgery

BACKGROUND

After nearly a decade of new data, the Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons was updated for prophylactic systemic antibiotics to prevent surgical-site infections (SSI). Pharmacotherapeutic concepts using antimicrobial stewardship were applied for clinical interpretation and management to optimize patient outcomes and minimize resistance.

METHODS

PRISMA, Cochrane, and GRADE certainty of evidence guidelines were implemented for the structure and synthesis of the review. PubMed, Embase, Cochrane Library, Web of Science, and Scopus databases were systematically and independently searched for randomized controlled trials (RCTs). The authors included patients who had plastic and reconstructive surgery and were treated with prophylactic systemic antibiotics administered perioperatively (preoperatively, intraoperatively, or postoperatively). Comparisons were made between active interventions and nonactive interventions (placebo) at different prespecified durations to determine the development of an SSI. Meta-analyses were performed.

RESULTS

The authors included 138 RCTs that met eligibility criteria. RCTs consisted of 18 breast, 10 cosmetic, 21 hand/peripheral nerve, 61 pediatric/craniofacial, and 41 reconstructive studies. The authors examined bacterial data extracted from studies for patients who did or did not take prophylactic systemic antibiotics for prevention of SSI. Clinical recommendations were provided using level I evidence.

CONCLUSIONS

Surgeons have long been overprescribing systemic antibiotic prophylaxis in plastic and reconstructive surgery. Evidence supports antibiotic prophylaxis to prevent SSI for specific indications and durations. Prolonged antibiotic use has not been linked to reductions in SSIs, and misuse may increase the bacterial diversity of infections. Greater efforts should focus on transitioning from practice-based to pharmacotherapeutic evidence-based medicine.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

A randomized clinical trial of antibiotic treatment duration in preterm premature rupture of membranes: 7 days vs until delivery

BACKGROUND

Antibiotic treatment in preterm premature rupture of membranes can prolong the interval from membrane rupture to delivery and improve neonatal outcomes. However, the duration of antibiotic treatment for preterm premature rupture of membranes has been rarely compared in prospective studies.

OBJECTIVE

This study aimed to investigate the optimal duration of antibiotic treatment for premature rupture of membranes. We performed a randomized controlled trial comparing neonatal morbidity and infantile neurologic outcomes between 2 groups of patients with preterm premature rupture of membranes who received antibiotic treatment for 7 days or until delivery, respectively.

STUDY DESIGN

This prospective randomized study included patients who were diagnosed with preterm premature rupture of membranes between 22+0 weeks and 33+6 weeks of gestation. The enrolled patients were randomly assigned to receive intravenous cefazolin (1 g dosage every 12 hours) and oral clarithromycin (500 mg dosage every 12 hours) either for 7 days or until delivery. The study protocol was registered at ClinicalTrials.gov under identifier NCT01503606. The primary outcome was a neonatal composite morbidity, and the secondary outcome was neurologic outcomes at 12 months of corrected age. We enrolled 151 patients and allocated 75 and 76 of them to the 7-day and until-delivery groups, respectively. Analysis was done by per protocol.

RESULTS

After excluding cases lost to follow-up and those with protocol violations, 63 (7-day regimen) and 61 (until-delivery regimen) patients with preterm premature rupture of membranes and their babies were compared. There was no significant difference in the pregnancy outcomes, including gestational age at delivery and the interval from rupture of membranes to delivery, between the 2 groups. Among the neonatal outcomes, bronchopulmonary dysplasia, intraventricular hemorrhage, retinopathy of prematurity, necrotizing enterocolitis, and proven neonatal sepsis did not differ between the groups. However, the rates of respiratory distress syndrome (32.8% vs 50.8%; P=.039) and composite neonatal morbidities (34.4% vs 53.9%; P=.026) were lower in the until-delivery group than in the 7-day group. This difference remained statistically significant after a multivariable analysis adjusting for maternal age, twin pregnancy, antenatal corticosteroids treatment, gestational age at delivery, interval from rupture of membranes to delivery, and clinical chorioamnionitis. Infantile neurologic outcomes were evaluated in 71.4% of the babies discharged alive and did not differ between the groups.

CONCLUSION

Overall, the until-delivery regimen of cefazolin and clarithromycin in preterm premature rupture of membranes led to a lower incidence of composite neonatal morbidity and respiratory distress syndrome than the 7-day regimen, and both regimens otherwise showed similar individual neonatal morbidities and infantile neurologic outcomes.

Antibiotic prophylaxis in breast cancer surgery (PAUS trial): randomised clinical double-blind parallel-group multicentre superiority trial

BACKGROUND

Participants were patients with invasive breast cancer undergoing primary surgery. The aim was to test whether a single dose of amoxicillin-clavulanic acid would reduce wound infection at 30 days postoperatively, and to identify risk factors for infection.

METHODS

Participants were randomised to either a single bolus of 1.2 g intravenous amoxicillin-clavulanic acid after the induction of anaesthesia (intervention) or no antibiotic (control). The primary outcome was the incidence of wound infection at 30 days postoperatively.

RESULTS

There were 871 evaluable patients. Of these, 438 received prophylactic antibiotic and 433 served as controls. Seventy-one (16.2 per cent) patients in the intervention group developed a wound infection by 30 days, while there were 83 (19.2 per cent) infections in the control group. This was not statistically significant (odds ratio (OR) 0.82, 95 per cent c.i. 0.58 to 1.15; P = 0.250). The risk of infection increased for every 5 kg/m2 of BMI (OR 1.29, 95 per cent c.i. 1.10 to 1.52; P = 0.003). Patients who were preoperative carriers of Staphylococcus aureus had an increased risk of postoperative wound infection; however, there was no benefit of preoperative antibiotics for patients with either a high BMI or who were carriers of S. aureus.

CONCLUSION

There was no statistically significant or clinically meaningful reduction in wound infection at 30 days following breast cancer surgery in patients who received a single dose of amoxicillin-clavulanic acid preoperatively.

REGISTRATION NUMBER

N0399145605 (National Research Register).

Antibiotic administration reduces the rate of intraamniotic inflammation in preterm prelabor rupture of the membranes

BACKGROUND

Preterm prelabor rupture of the membranes (PPROM) is frequently complicated by intraamniotic inflammatory processes such as intraamniotic infection and sterile intraamniotic inflammation. Antibiotic therapy is recommended to patients with PPROM to prolong the interval between this complication and delivery (latency period), reduce the risk of clinical chorioamnionitis, and improve neonatal outcome. However, there is a lack of information regarding whether the administration of antibiotics can reduce the intensity of the intraamniotic inflammatory response or eradicate microorganisms in patients with PPROM.

OBJECTIVE

The first aim of the study was to determine whether antimicrobial agents can reduce the magnitude of the intraamniotic inflammatory response in patients with PPROM by assessing the concentrations of interleukin-6 in amniotic fluid before and after antibiotic treatment. The second aim was to determine whether treatment with intravenous clarithromycin changes the microbial load of Ureaplasma spp DNA in amniotic fluid.

STUDY DESIGN

A retrospective cohort study included patients who had (1) a singleton gestation, (2) PPROM between 24+0 and 33+6 weeks, (3) a transabdominal amniocentesis at the time of admission, and (4) intravenous antibiotic treatment (clarithromycin for patients with intraamniotic inflammation and benzylpenicillin/clindamycin in the cases of allergy in patients without intraamniotic inflammation) for 7 days. Follow-up amniocenteses (7th day after admission) were performed in the subset of patients with a latency period lasting longer than 7 days. Concentrations of interleukin-6 were measured in the samples of amniotic fluid with a bedside test, and the presence of microbial invasion of the amniotic cavity was assessed with culture and molecular microbiological methods. Intraamniotic inflammation was defined as a bedside interleukin-6 concentration ≥745 pg/mL in the samples of amniotic fluid. Intraamniotic infection was defined as the presence of both microbial invasion of the amniotic cavity and intraamniotic inflammation; sterile intraamniotic inflammation was defined as the presence of intraamniotic inflammation without microbial invasion of the amniotic cavity.

RESULTS

A total of 270 patients with PPROM were included in this study: 207 patients delivered within 7 days and 63 patients delivered after 7 days of admission. Of the 63 patients who delivered after 7 days following the initial amniocentesis, 40 underwent a follow-up amniocentesis. Patients with intraamniotic infection (n = 7) and sterile intraamniotic inflammation (n = 7) were treated with intravenous clarithromycin. Patients without either microbial invasion of the amniotic cavity or intraamniotic inflammation (n = 26) were treated with benzylpenicillin or clindamycin. Treatment with clarithromycin decreased the interleukin-6 concentration in amniotic fluid at the follow-up amniocentesis compared to the initial amniocentesis in patients with intraamniotic infection (follow-up: median, 295 pg/mL, interquartile range [IQR], 72-673 vs initial: median, 2973 pg/mL, IQR, 1750-6296; P = .02) and in those with sterile intraamniotic inflammation (follow-up: median, 221 pg/mL, IQR 118-366 pg/mL vs initial: median, 1446 pg/mL, IQR, 1300-2941; P = .02). Samples of amniotic fluid with Ureaplasma spp DNA had a lower microbial load at the time of follow-up amniocentesis compared to the initial amniocentesis (follow-up: median, 1.8 × 104 copies DNA/mL, 2.9 × 104 to 6.7 × 108 vs initial: median, 4.7 × 107 copies DNA/mL, interquartile range, 2.9 × 103 to 3.6 × 107; P = .03).

CONCLUSION

Intravenous therapy with clarithromycin was associated with a reduction in the intensity of the intraamniotic inflammatory response in patients with PPROM with either intraamniotic infection or sterile intraamniotic inflammation. Moreover, treatment with clarithromycin was related to a reduction in the load of Ureaplasma spp DNA in the amniotic fluid of patients with PPROM <34 weeks of gestation.

Breast cancer and the black swan

Most current research in cancer is attempting to find ways of preventing patients from dying after metastatic relapse. Driven by data and analysis, this project is an approach to solve the problem upstream, i.e., to prevent relapse. This project started with the unexpected observation of bimodal relapse patterns in breast and a number of other cancers. This was not explainable with the current cancer paradigm that has guided cancer therapy and early detection for many years. After much analysis using computer simulation and input from a number of medical specialties, we eventually came to the conclusion that the surgery to remove the primary tumour produced systemic inflammation for a week after surgery. This systemic inflammation apparently caused exits of cancer cells and micrometastases from dormant states and resulted in relapses in the first 3 years post-surgery. It was determined in a retrospective study that the common inexpensive perioperative non-steroidal anti-inflammatory drug (NSAID) ketorolac could curtail the early relapse events after breast cancer surgery. A second retrospective study strongly confirmed this but an apparently underpowered prospective study showed no advantage. We are analysing these data and are now proposing to test the perioperative NSAID at Beth Israel Deaconess Medical Centre with triple-negative breast cancer (TNBC) patients, the category that could respond best to the perioperative NSAID. If this works as well as we expect, we would then transfer this technology to low- and/or middle-incomes countries (LMICs), starting with Nigeria where early onset type of TNBC is common. There is an unmet need in LMICs, especially in countries like Nigeria (190 million population), for a means to prevent surgery induced relapse that we are attempting to resolve. This work aims, thus, to describe eventual mechanisms, and ways to test a solution addressing an unmet need. But first, we consider the context, including within an historical perspective, important to explain how and why a Kuhnian paradigm shift may be considered.

Peri-Operative Antibiotic Prophylaxis Does Not Reduce Surgical Site Infection in Breast Cancer

Background: The reported rate of surgical site infection (SSI) in breast surgery is often higher than expected. Using antibiotic prophylaxis to reduce SSI is debatable because of the risk of developing bacteria resistance and the cost burden. In this study, we evaluated the effectiveness of antibiotic prophylaxis in breast surgery and the factors predisposing patients to SSI. Methods: A retrospective-prospective (ambispective) study was conducted in the Department of Breast Surgery, Qilu Hospital, P.R. China. The retrospective antibiotic-using group was composed of patients found to have breast cancer between January 2008 and October 2010. The prospective non-antibiotic-using group was composed of patients identified between November 2010 and November 2013. Pre-operative, peri-operative, and post-operative clinical data were analyzed. Results: The SSI rate of the non-prophylaxis and prophylaxis groups was 1.1% (11/1,022) and 1.2% (12/1,034), respectively. Neoadjuvant chemotherapy was related to SSI in the non-prophylaxis group (p = 0.026). Staphylococcus aureus was the predominant microorganism responsible for SSI, without obvious resistance to a widely used first-generation cephalosporin. Conclusions: Peri-operative antibiotic prophylaxis is of no significant value in preventing SSI in breast cancer surgery. Our results indicated that neoadjuvant chemotherapy might be a risk factor doe SSI, but further research is needed because of the sample size disparity between infected and uninfected groups.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery. This is an update of a Cochrane Review first published in 2005 and last updated in 2014.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this fourth update, in August 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

We included randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Three review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria. We contacted study authors to obtain missing information. We evaluated the certainty of evidence using the GRADE approach. We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

A total of 11 randomised controlled trials (2867 participants) were included in the review. No new studies were identified in this update. All studies included breast cancer patients and were based in the hospital setting. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with placebo or no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively probably reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85; moderate certainty evidence). Anticipated absolute effects were calculated for the outcome incidence of SSI; 105 per 1000 for the none or placebo group and 71 per 1000 (95% CI 56 to 89) for the preoperative antibiotic prophylaxis group. Analysis of the single study comparing perioperative antibiotic with no antibiotic was inconclusive for incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95; very low certainty evidence). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.Secondary outcomes were not consistently included in the studies investigating preoperative antibiotic prophylaxis. It is very uncertain whether there is a difference in incidence of adverse events between the treatment and no treatment or placebo groups (10 studies, 2818 participants); very low certainty evidence downgraded one level for serious risk of bias, one level for serious inconsistency and one level for serious imprecision. It is unclear whether there is a difference in time to onset of infection between the treatment and no treatment or placebo groups (4 studies, 1450 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. It is unclear whether there is a difference in rates of readmission to hospital between the treatment and placebo groups (3 studies, 784 participants); low certainty evidence downgraded one level for serious inconsistency and one level for serious risk of bias. It is unclear whether there is a difference in cost of care between the treatment and no treatment or placebo groups (2 studies, 510 participants); low certainty evidence downgraded one level for serious risk of bias and one level for serious inconsistency. No analysable secondary outcome data were reported for the single study evaluating perioperative antibiotics.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively probably reduce the risk of SSI in patients undergoing surgery for breast cancer. However, it is very uncertain whether there is an effect on incidence of adverse events. Furthermore, the effects on time to onset of infection, readmission to hospital and cost of care remain unclear. Further studies are required to establish the best protocols for clinical practice.

Identifying the superior antibiotic prophylaxis strategy for breast surgery: A network meta-analysis

BACKGROUND

The clinical roles of different antibiotic prophylaxis strategies for breast surgery remains large unknowns. The aim of this study is to evaluate different antibiotic prophylaxis strategies based on a network meta-analysis.

METHODS

We initially retrieved literature from globally recognized databases, namely, MEDLINE, EMBASE and Cochrane Central, to address relative randomized controlled trials (RCTs) investigating the antibiotic prophylaxis strategies for breast surgery. Relative postoperative infection rates were quantitatively pooled and estimated based on the Bayesian theorem. Values of surface under the cumulative ranking curve (SUCRA) probabilities were calculated and ranked. Additional pairwise meta-analyses were performed to validate differences between the respective strategies at the statistical level for further explanations.

RESULTS

After a detailed review, a total of 14 RCTs containing 6 different strategies were included for the network meta-analysis. The results indicated that the application of antibiotics administered during pre- plus post- plus intraoperative periods possessed the highest possibility of having the best clinical effects (SUCRA, 0.40), followed by intraoperative administration alone (SUCRA, 0.35) and pre- plus intraoperative administrations (SUCRA, 0.20). Moreover, an additional pairwise meta-analysis determined that pre- and intraoperative-related strategies significantly reduced postoperative infections at a statistical level.

CONCLUSION

Based on the current evidence, we concluded that application of antibiotics administered during pre- plus post- plus intraoperative periods seemed to reveal superior benefits. However, the essential roles of pure intraoperative and postoperative application were still need to be further validated.

Effects of pre-transplant azithromycin administration on kidney graft function: study protocol for a double-blind randomized clinical trial

Background

Kidney transplantation is the best strategy for the management of end-stage renal disease; however, the outcomes need to improve further. Macrolides show antimicrobial and anti-inflammatory properties in chronic diseases and intraoperatively, and can accumulate in tissues for extended periods. Therefore, theoretically, when administered to a donor and because of accumulation in the donor kidney, macrolides can cause graft immunomodulation and improve kidney transplantation outcomes.

Methods

This study is a single-center, randomized clinical trial. A total of 60 kidney donors will be randomly allocated to the azithromycin or placebo group and treated with a single dose (1 g) of azithromycin or placebo, respectively, 1 day before surgery. Recruitment commenced in September 2016 and is expected to be completed by March 2018. The primary outcome is kidney graft function. The secondary outcomes include rejection rate, urinary tract infections in graft recipients, pain and systemic inflammatory response syndrome in live donors, and complications in both donors and recipients. Outcomes will be evaluated at baseline and every day in the first week after transplantation, as well as at 1 and 3 months post transplantation. Adverse reactions will be documented. If the efficacy of azithromycin in reducing adverse outcomes is confirmed, it would serve as an easy to use, economic intervention able to lower post-transplantation risks.

Discussion

Short and mid-term analyses of blood and urine samples as well as immunological assays will facilitate a more in-depth analysis of the effects of azithromycin on transplantation outcomes.

Trial registration

Iranian Clinical Trial Registry, IRCT201606141853N11, registered on September 5, 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2744-y) contains supplementary material, which is available to authorized users.

Immediate postoperative inflammation is an important prognostic factor in breast cancer

OBJECTIVE

Inflammation is associated with worse outcomes in cancer. Operations induce an acute inflammatory response and could impact the clinical outcomes in breast cancer. The neutrophil-lymphocyte ratio (NLR) is a well-known indicator of inflammation. We investigated the prognostic significance of perioperative inflammation with the NLR in breast cancer.

METHODS

We reviewed the clinical and pathological records of women diagnosed with invasive breast carcinoma at the Samsung Medical Center between 2000 and 2010. The NLR levels in the immediate preoperative period and the postoperative periods (1 week and 1 month) were assessed.

RESULTS

The NLRs of a total of 3,116 breast cancer patients were examined. In the univariate analysis, the NLR in postoperative week 1, total mastectomy, the presence of lymphovascular invasion, a higher nuclear grade and pathologic TNM stage, and negative hormone receptor and subtypes were factors associated with poor disease-specific survival. The NLR in postoperative week 1 remained a significant prognostic factor in the multivariate analysis. A cutoff level of 5.2, determined by the minimum p value approach, was found to be a significant level for discriminating the impact on breast cancer-specific mortality (p = 0.0116 adjusted by the Bonferroni correction).

CONCLUSIONS

Immediate postoperative inflammation is an important prognostic marker in breast cancer patients.

Repurposing Drugs in Oncology (ReDO)-clarithromycin as an anti-cancer agent

Clarithromycin (CAM) is a well-known macrolide antibiotic available as a generic drug. CAM is traditionally used for many types of bacterial infections, treatment of Lyme disease and eradication of gastric infection with Helicobacter pylori. Extensive preclinical and clinical data demonstrate a potential role for CAM to treat various tumours in combination with conventional treatment. The mechanisms of action underlying the anti-tumour activity of CAM are multiple and include prolonged reduction of pro-inflammatory cytokines, autophagy inhibition, and anti-angiogenesis. Here, we present an overview of the current preclinical (in vitro and in vivo) and clinical evidence supporting the role of CAM in cancer. Overall these findings justify further research with CAM in many tumour types, with multiple myeloma, lymphoma, chronic myeloid leukaemia (CML), and lung cancer having the highest level of evidence. Finally, a series of proposals are being made to further investigate the use of CAM in clinical trials which offer the greatest prospect of clinical benefit to patients.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this third update we searched the Cochrane Wounds Group Specialised Register (5 December 2013); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of eleven studies (2867 participants) were included in the review. Ten studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.67, 95% confidence interval (CI) 0.53 to 0.85). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Reduction of breast cancer relapses with perioperative non-steroidal anti-inflammatory drugs: new findings and a review

To explain a bimodal pattern of hazard of relapse among early stage breast cancer patients identified in multiple databases, we proposed that late relapses result from steady stochastic progressions from single dormant malignant cells to avascular micrometastases and then on to growing deposits. However in order to explain early relapses, we had to postulate that something happens at about the time of surgery to provoke sudden exits from dormant phases to active growth and then to detection. Most relapses in breast cancer are in the early category. Recent data from Forget et al. suggest an unexpected mechanism. They retrospectively studied results from 327 consecutive breast cancer patients comparing various perioperative analgesics and anesthetics in one Belgian hospital and one surgeon. Patients were treated with mastectomy and conventional adjuvant therapy. Relapse hazard updated Sept 2011 are presented. A common Non-Steroidal Anti-Inflammatory Drug (NSAID) analgesic used in surgery produced far superior disease-free survival in the first 5 years after surgery. The expected prominent early relapse events in months 9-18 are reduced 5-fold. If this observation holds up to further scrutiny, it could mean that the simple use of this safe, inexpensive and effective anti-inflammatory agent at surgery might eliminate early relapses. Transient systemic inflammation accompanying surgery could facilitate angiogenesis of dormant micrometastases, proliferation of dormant single cells, and seeding of circulating cancer stem cells (perhaps in part released from bone marrow) resulting in early relapse and could have been effectively blocked by the perioperative anti-inflammatory agent.

Management of granulomatous mastitis: a series of 14 patients

OBJECTIVE

To analyze the history of relapses in idiopathic granulomatous mastitis (IGM) and to define an appropriate therapeutic strategy. The duration and number of relapses are unpredictable, and the roles of surgery and corticosteroids remain controversial.

STUDY DESIGN

A series of 14 patients with IGM and a mean follow-up of 61.5 ± 73 (SD) months were retrospectively studied in the Gynecology Unit (Hotel Dieu Hospital, Paris, France). Main outcome measure was number of relapses per year before and following corticosteroid therapy. Comparison of the two groups was performed with matched t-test.

RESULTS

A total of 125 episodes were analyzed. Before steroid treatment, 60 recurrences occurred, corresponding to a mean of 4.03 ± 4.22 (SD) relapses per year. After the first treatment with prednisone, patients experienced 47 relapses, representing a mean of 1.11 ± 1.27 (SD) relapses per year (p = 0.0371).

CONCLUSIONS

Medical treatment with steroid reduces the duration and number of episodes. It also prevents the need for invasive breast surgery.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between 3% and 15%, higher than average for a clean surgical procedure. Pre- and perioperative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no consensus on the use of prophylactic antibiotics for breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic (pre- or perioperative) antibiotics on the incidence of surgical site infection (SSI) after breast cancer surgery.

SEARCH METHODS

For this second update we searched the Cochrane Wounds Group Specialised Register (searched 31 August 2011); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2008 to August Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 30 August 2011); Ovid EMBASE (1980 to 2011 Week 34); and EBSCO CINAHL (2008 to 25 August 2011). We applied no language or date restrictions.

SELECTION CRITERIA

Randomised controlled trials of pre- and perioperative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were rates of surgical site infection (SSI) and adverse reactions.

DATA COLLECTION AND ANALYSIS

Two review authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

A total of nine studies (2260 participants) is included in the review. Eight studies evaluated preoperative antibiotic compared with no antibiotic or placebo. One study evaluated perioperative antibiotic compared with no antibiotic. Pooling of the results demonstrated that prophylactic antibiotics administered preoperatively significantly reduce the incidence of SSI for patients undergoing breast cancer surgery without reconstruction (pooled risk ratio (RR) 0.71, 95% confidence interval (CI) 0.53 to 0.94). Analysis of the single study comparing perioperative antibiotic with no antibiotic found no statistically significant effect of antibiotics on the incidence of SSI (RR 0.11, 95% CI 0.01 to 1.95). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics administered preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer. Further studies involving patients undergoing immediate breast reconstruction are needed as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Macrolide immunomodulatory effects and symptom resolution in acute exacerbation of chronic bronchitis and acute maxillary sinusitis: a focus on clarithromycin

Bacterial respiratory tract infections are common in the primary care setting and patients often seek the assistance of a healthcare professional in order to achieve resolution of their symptoms. Antibiotic agents that offer rapid symptom relief, in addition to excellent bacteriological and clinical cure, are highly desired. Macrolides have proven to be highly effective in treating acute bacterial exacerbations of chronic bronchitis and acute maxillary sinusitis. In addition, immunomodulatory effects that may contribute to symptom resolution have been reported. This article reviews current literature on symptom resolution in acute bacterial exacerbations of chronic bronchitis and acute maxillary sinusitis, with a focus on clarithromycin, and explores the potential mechanisms that may contribute to this action.

Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery

BACKGROUND

Surgery has been used as part of breast cancer treatment for centuries; however any surgical procedure has the potential risk of infection. Infection rates for surgical treatment of breast cancer are documented at between three and 15%, higher than average for a clean surgical procedure. Pre and peri-operative antibiotics have been found to be useful in lowering infection rates in other surgical groups, yet there is no current consensus on prophylactic antibiotic use in breast cancer surgery.

OBJECTIVES

To determine the effects of prophylactic antibiotics on the incidence of surgical site infection after breast cancer surgery.

SEARCH STRATEGY

We searched the Cochrane Wounds and Breast Cancer Groups Specialised Registers, the Cochrane Central Register of Controlled Trials (CENTRAL) issue 1 2006. MEDLINE 2002-2005, EMBASE 1980-2005, NRR issue 1 2005, CINAHL 1982-2004 and SIGLE 1976-2004. Companies and experts in the field were contacted and reference lists were checked. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials of pre and peri-operative antibiotics for patients undergoing surgery for breast cancer were included. Primary outcomes were, incidence of breast wound infection and adverse reactions to treatment.

DATA COLLECTION AND ANALYSIS

Two authors independently examined the title and abstracts of all studies identified by the search strategy, then assessed study quality and extracted data from those that met the inclusion criteria.

MAIN RESULTS

Six studies met the inclusion criteria. All six evaluated pre-operative antibiotic compared with no antibiotic or placebo. Pooling of the results demonstrated that prophylactic antibiotics significantly reduce the incidence of surgical site infection for patients undergoing breast cancer surgery without reconstruction (pooled RR 0.66, 95% CI, 0.48 to 0.89). No studies presented separate data for patients who underwent reconstructive surgery at the time of removal of the breast tumour.

AUTHORS' CONCLUSIONS

Prophylactic antibiotics reduce the risk of surgical site infection in patients undergoing surgery for breast cancer. The potential morbidity caused by infection, such as delays in wound healing or adjuvant cancer treatments must be balanced against the cost of treatment and potential adverse effects such as drug reactions or increased bacterial resistance. Further studies of patients undergoing immediate breast reconstruction would be useful as studies have identified this group as being at higher risk of infection than those who do not undergo immediate breast reconstruction.

Anti-inflammatory effects of macrolides—an underappreciated benefit in the treatment of community-acquired respiratory tract infections and chronic inflammatory pulmonary conditions?

BACKGROUND

It has been recognized for more than 20 years that the macrolides have immunomodulatory effects that are beneficial for those suffering from chronic pulmonary inflammatory syndromes, such as diffuse panbronchiolitis, cystic fibrosis, asthma and bronchiectasis. The macrolides have consistently been associated with decreased length of stay and mortality when used alone or in combination with beta-lactam antibiotics. This effect can be demonstrated against combinations consisting of beta-lactams and other antibiotics active against 'atypical chest pathogens' when treating community-acquired pneumonia (CAP) in hospitalized patients. As such, it appears that the macrolides' effects in CAP patients are more than just antibacterial in nature. AIMS OF THIS REVIEW: This review aims: to give the reader information on the background areas described, as well as related areas; to review the CAP benefits with macrolides and how they may be related to the immunomodulatory properties they demonstrate, albeit in a shorter period of time than previously demonstrated with chronic pulmonary disorders; to use ex vivo data to support these extrapolations.

LITERATURE SEARCH

A literature search using Medline was conducted from 1966 onwards, searching for articles with relevant key words such as macrolide, diffuse panbronchiolitis, community-acquired pneumonia, biofilm, immunomodulation, cystic fibrosis, erythromycin, clarithromycin, roxithromycin and azithromycin, bronchiectasis and asthma. When appropriate, additional references were found from the bibliographies of identified papers of interest. Any relevant scientific conference proceedings or medical texts were checked when necessary.

CONCLUSIONS

(1) Research into macrolide immunomodulation for chronic pulmonary disorders demonstrates consistent positive effects, although of types other than seen with diffuse panbronchiolitis. These effects, together with their inhibitory activity on biofilms, have the potential to make them a useful option. (2) The benefits for CAP are consistent, and higher when a macrolide is given with another atypical agent than if the other atypical agent is given alone, suggesting a non-antibacterial benefit. (3) Recent research of the immunomodulatory properties of azithromycin imply that azithromycin may have a previously unknown short-term biphasic effect on inflammation modulation: enhancement of host defence mechanisms shortly after initial administration followed by curtailment of local infection/inflammation in the following period. (4) Additional in vivo research is needed prior to developing any firm conclusions.

Clinical and molecular epidemiology of erythromycin-resistant beta-hemolytic lancefield group G streptococci causing bacteremia

Among 100 patients with group G beta-hemolytic streptococcal bacteremia in a 6-year period (1997 to 2002), seven had bacteremia caused by erythromycin-resistant strains. Five of the seven patients had cellulitis and/or abscesses. The two isolates resistant to erythromycin and clindamycin possessed erm genes, one ermTR and the other ermB. The five isolates resistant to erythromycin but sensitive to clindamycin and one of those resistant to both erythromycin and clindamycin possessed mef genes.

The study of cytokine dynamics at the operation site after mastectomy

Twenty-nine patients, who each received modified radical mastectomy, were recruited for this study. Wounds were inspected daily for the presence of flap necrosis, infection, and seroma. Drain fluid (20 ml) was collected at 6 a.m. on postoperative days 1, 2, and 5 and the levels of interleukin (IL)-4, IL-6, tumor necrosis factor-alpha, and interferon-gamma determined. For patients with no wound events, only IL-6 levels were elevated during the initial phase, but in the later phase the IL-6 levels dropped with a corresponding rise in tumor necrosis factor-alpha levels. In patients with flap necrosis, there was a sequential rise of IL-4 on day 1, IL-6 on day 2, and tumor necrosis factor-alpha on day 5, but only IL-4 was found to be a statistically significant factor associated with necrosis. In patients with seroma, the levels of IL-4 and interferon-gamma were persistently low and were both statistically significant. To conclude, IL-6 and tumor necrosis factor-alpha are important in normal postoperative wound healing and IL-4 and interferon-gamma may be associated with postoperative necrosis and seroma.